Fluid Intake in Critically Ill Patients: The "Save Useless Fluids For Intensive Resuscitation" Multicenter Prospective Cohort Study.

OBJECTIVES: Patients at risk of adverse effects related to positive fluid balance could benefit from fluid intake optimization. Less attention is paid to nonresuscitation fluids. We aim to evaluate the heterogeneity of fluid intake at the initial phase of resuscitation. DESIGN: Prospective multicenter cohort study. SETTING: Thirty ICUs across France and one in Spain. PATIENTS: Patients requiring vasopressors and/or invasive mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All fluids administered by vascular or enteral lines were recorded over 24 hours following admission and were classified in four main groups according to their predefined indication: fluids having a well-documented homeostasis goal (resuscitation fluids, rehydration, blood products, and nutrition), drug carriers, maintenance fluids, and fluids for technical needs. Models of regression were constructed to determine fluid intake predicted by patient characteristics. Centers were classified according to tertiles of fluid intake. The cohort included 296 patients. The median total volume of fluids was 3546 mL (interquartile range, 2441-4955 mL), with fluids indisputably required for body fluid homeostasis representing 36% of this total. Saline, glucose-containing high chloride crystalloids, and balanced crystalloids represented 43%, 27%, and 16% of total volume, respectively. Whatever the class of fluids, center of inclusion was the strongest factor associated with volumes. Compared with the first tertile, the difference between the volume predicted by patient characteristics and the volume given was +1.2 ± 2.0 L in tertile 2 and +3.0 ± 2.8 L in tertile 3. CONCLUSIONS: Fluids indisputably required for body fluid homeostasis represent the minority of fluid intake during the 24 hours after ICU admission. Center effect is the strongest factor associated with the volume of fluids. Heterogeneity in practices suggests that optimal strategies for volume and goals of common fluids administration need to be developed.

Impact of COVID-19 pandemic waves on health-care worker hand hygiene activity in department of medicine and ICU as measured by an automated monitoring system.

BACKGROUND: Hand hygiene (HH) compliance among health-care workers is important for preventing transmission of infectious diseases. AIM: To describe health-care worker hand hygiene activity in ICU and non-ICU patients' rooms, using an automated monitoring system (AMS), before and after the onset of the COVID-19 pandemic. METHODS: At the Intercommunal Hospital of Créteil, near Paris, France, alcohol-based hand sanitizer (ABHS) consumption in the Department of Medicine (DM) and ICU was recorded using an AMS during four periods: before, during, and after the first wave of the COVID-19 pandemic, and during its second wave. FINDINGS: From 1st February to 30th November 2020, in the DM, the mean number of doses per patient-day for each of the four periods was, respectively, 5.7 (±0.3), 19.4 (±1.3), 17.6 (±0.7), and 7.9 (±0.2, P < 0.0001). In contrast, ICU ABHS consumption remained relatively constant. In the DM, during the pandemic waves, ABHS consumption was higher in rooms of COVID-19 patients than in other patients' rooms. Multivariate analysis showed ABHS consumption was associated with the period in the DM, and with the number of HCWs in the ICU. CONCLUSION: An AMS allows real-time collection of ABHS consumption data that can be used to adapt training and prevention measures to specific hospital departments.

[COVID-19 epidemic, a challenge successfully overcome by intensive care nurses]. / L'épidémie de Covid-19, une mise à l'épreuve réussie pour les infirmiers de réanimation.

The COVD-19 wave of spring 2020 had a major impact on French intensive care departments. The intense activity, the support of reinforcements in the acquisition of the necessary skills and their capacity to adapt made intensive care nurses key players in this crisis. Grouped together within the French National Federation of Intensive Care Nurses, they are campaigning to have the specificity of their practice to be recognised and for the creation of certified training in order to meet public healthcare needs not currently fulfilled.

ICU Patients Requiring Renal Replacement Therapy Initiation: Fewer Survivors and More Dialysis Dependents From 80 Years Old.

OBJECTIVES: To assess the role of advanced age on survival and dialysis dependency after initiation of renal replacement therapy for acute kidney injury. DESIGN: Retrospective pooled analysis of prospectively collected data. SETTING: ICUs of two teaching hospitals in Paris area, France. SUBJECTS: One thousand five hundred thirty adult patients who required renal replacement therapy initiation in the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Survival and post acute kidney injury chronic dialysis dependency were assessed at hospital discharge according to the quintile (Q) of age. The oldest quintile included 289 patients 80 years old and over. Seventy-three percent of included patients had respiratory and hemodynamic supports at renal replacement therapy initiation, similarly distributed across quintiles. Mortality increased with age strata from 63% in Q1 (≤ 52 yr) to 76% in Q5 (≥ 80 yr) (p < 0.001). After adjustment, age did not increase the risk of death up to 80 years. The oldest patients (≥ 80 yr) had a significant higher risk of dying (adjusted odds ratio, 2.59; 95% CI, 1.66-4.03). Dialysis dependency was more frequent among survivors 80 years old or older (30% vs 14%; p = 0.001). Age 80 years old or older was an independent risk for dialysis dependency only for patients with prior advanced chronic kidney disease (p = 0.04). Baseline estimated glomerular filtration rate was the only one predictor of dialysis dependency identified. CONCLUSIONS: Patients with advanced age represent a substantial subgroup of patients requiring renal replacement therapy in the ICU. From 80 years, age should be considered as an additional risk of dying over the severity of organ failures. Patients 80 years old or older are likely to recover sufficient renal function allowing renal replacement therapy discontinuation when baseline estimated glomerular filtration rate is above 44 mL/min/1.73 m. At 3 months, only 6% were living at home, dialysis independent.

Epidemiology of Weaning Outcome according to a New Definition. The WIND Study.

RATIONALE: The weaning process concerns all patients receiving mechanical ventilation. A previous classification into simple, prolonged, and difficult weaning ignored weaning failure and presupposed the use of spontaneous breathing trials. OBJECTIVES: To describe the weaning process, defined as starting with any attempt at separation from mechanical ventilation and its prognosis, according to a new operational classification working for all patients under ventilation. METHODS: This was a multinational prospective multicenter observational study over 3 months of all patients receiving mechanical ventilation in 36 intensive care units, with daily collection of ventilation and weaning modalities. Pragmatic definitions of separation attempt and weaning success allowed us to allocate patients in four groups. MEASUREMENTS AND MAIN RESULTS: A total of 2,729 patients were enrolled. Although half of them could not be classified using the previous definition, 99% entered the groups on the basis of our new definition as follows: 24% never started a weaning process, 57% had a weaning process of less than 24 hours (group 1), 10% had a difficult weaning of more than 1 day and less than 1 week (group 2), and 9% had a prolonged weaning duration of 1 week or more (group 3). Duration of ventilation, intensive care unit stay, and mortality (6, 17, and 29% for the three groups, respectively) all significantly increased from one group to the next. The unadjusted risk of dying was 19% after the first separation attempt and increased to 37% after 10 days. CONCLUSIONS: A new classification allows us to categorize all weaning situations. Every additional day without a weaning success after the first separation attempt increases the risk of dying.

Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis.

RATIONALE: Many patients with severe acute respiratory distress syndrome (ARDS) caused by influenza A(H1N1) infection receive extracorporeal membrane oxygenation (ECMO) as a rescue therapy. OBJECTIVES: To analyze factors associated with death in ECMO-treated patients and the influence of ECMO on intensive care unit (ICU) mortality. METHODS: Data from patients admitted for H1N1-associated ARDS to French ICUs were prospectively collected from 2009 to 2011 through the national REVA registry. We analyzed factors associated with in-ICU death in ECMO recipients, and the potential benefit of ECMO using a propensity score-matched (1:1) cohort analysis. MEASUREMENTS AND MAIN RESULTS: A total of 123 patients received ECMO. By multivariate analysis, increasing values of age, lactate, and plateau pressure under ECMO were associated with death. Of 103 patients receiving ECMO during the first week of mechanical ventilation, 52 could be matched to non-ECMO patients of comparable severity, using a one-to-one matching and using control subjects only once. Mortality did not differ between the two matched cohorts (odds ratio, 1.48; 95% confidence interval, 0.68-3.23; P = 0.32). Interestingly, the 51 ECMO patients who could not be matched were younger, had lower Pa(o(2))/Fi(o(2)) ratio, had higher plateau pressure, but also had a lower ICU mortality rate than the 52 matched ECMO patients (22% vs. 50%; P < 0.01). CONCLUSIONS: Under ECMO, an ultraprotective ventilation strategy minimizing plateau pressure may be required to improve outcome. When patients with severe influenza A(H1N1)-related ARDS treated with ECMO were compared with conventionally treated patients, no difference in mortality rates existed. The unmatched, severely hypoxemic, and younger ECMO-treated patients had, however, a lower mortality.